Provider Demographics
NPI:1104530302
Name:LIBERATORE, JENNIFER ANN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:LIBERATORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 RIDING RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-1652
Mailing Address - Country:US
Mailing Address - Phone:410-991-7080
Mailing Address - Fax:
Practice Address - Street 1:308 RIDING RIDGE RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-1652
Practice Address - Country:US
Practice Address - Phone:410-991-7080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP438529183500000X
MD16591183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist